Clinical Documentation Specialist
Resume:
Toe Wai Aung
310-***-**** **********@*****.*** Gadsden, AL
PROFESSIONAL SUMMARY
Certified Coding Specialist (CCS) certified clinical documentation improvement professional with over 8+ years of experience. Possesses medical background knowledge from surgical techniques to current medical principles and guidelines through a foreign medical program. Extensive experience in providing Epic Systems and live support training to healthcare professionals. Works well across a multitude of work environments while ensuring accuracy and compliance completeness of patient medical records.
WORK EXPERIENCE
Riverview Regional Medical Center Gadsden, AL
Clinical Documentation Specialist Supervisor/Team Lead November 2016 - Present
• Manage the CDI program by reviewing overall quality and completeness of provider documentation, identifying missing links to accurately reflect patient condition and level of services assigned
• Lead a collaborative team of CDI, Coding, HIM, Case management and UR personnel to minimize denials, improve length of stay and performance for core measures including HACs/ECRIs
Strengthen the query management process by generating well-informed, compliant, credible queries and maintaining timeliness in query response (TAT 2 days) and the following escalation process
• Implemented the Documentation Fallout tool to ensure consistent documentation in patient charts and improved case mix index (CMI) by 0.4, GmLOS and severity of illness and risk of mortality rate
• Provide CDI training for patient care teams including physicians, residents and nurses while promoting habitual documentation procedures
• Lead meetings with executives, physicians, and healthcare professionals to update CDI progress
• Contribute to the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program
• Periodically analyze and report CDI metrics for continuous process improvement to executives and corporate office to ensure overall quality, integrity, and completeness of clinical documentation
Led the DRG Appeals case by conducting research on state and federal laws and statues regarding reimbursement
Riverview Regional Medical Center Gadsden, AL
Clinical Documentation Specialist May 2015 – November 2016
Increased accuracy of documentation resulting in a yearly increase in the Medicare blended rate
Increased the reimbursement on 25% of the charts reviewed while facilitating accurate MD documentation resulting in a DRG (final diagnosis) change
Reviewed patient medical records in EPIC system to ensure accuracy of physician documentation compared to the Medicare approved verbiage
Increased the accuracy of documentation and captured co-morbid conditions to reflect the mortality index of the facility more accurately
Facilitated improvement in the overall quality and completeness of medical record documentation process through the query process
Impacted financial reimbursement through improved quality of clinical documentation
Reviewed medical records for identified payer populations (Medicare, Medicaid, Blue Cross Blue Shield) as directed on admission records and throughout hospitalization period
Barr Clinic Yangon, Myanmar
Volunteer Doctor August - December 2013
Checked up patients and prescribed relevant medications or referred to specialists
Monitored medical treatments, diagnosis, and assessment of patients
Educated patients on prevention and detection of illness by providing resources and materials to the patients and families
Participated in public health and sanitation inspections and provided care instructions
Mandalay General Hospital Mandalay, Myanmar
Intern Doctor in Surgical Ward January – March 2012
Performed therapeutic procedures such as injections, suturing, wound care and infection management
Assisted surgeons during surgery and complicated medical procedures
Performed life-saving procedures (CPR) and sutured head injury patients with scalp lacerations in Neurosurgical Unit
Assisted doctors in treatment of patients with trauma and injuries in Emergency and Trauma Unit
Intern Doctor in Pediatrics Ward July - September 2012
Conducted daily ward rounds for checking progress, monitoring and allowing early discharge of patients under care
Assisted physicians with treatments and monitored patients with childhood diseases and other communicable diseases on daily basis
Worked cooperatively with Department of Preventive and Social Medicine in surveying health and sanitation status data and provided outreach for prevalent childhood diseases
Managed and monitored newborns with serious life-threatening diseases, infections, and congenital defects in Neonatal Care Unit
Intern Doctor in Medical Ward October - December 2012
Assisted in diagnosis and treatment of medical conditions under the supervision of attending physicians
Managed the outpatient unit, hospital admissions, patient progress, treatment, vital signs, laboratory, diagnosis and X-rays
Participated in quality management and improvement efforts to provide patients with the best care
EDUCATION
Bachelor’s of Medicine & Bachelor's of Surgery (M.B, B.S) February 2013
University of Medicine, Mandalay Mandalay, Myanmar
SKILLS
Medical history documentation, Medical Diagnosis and treatment, Patient Assessment and care, Electronic Health Records (EHR), Patient Communication and Education
Clinical Documentation Improvement, ICD-10 Coding, Medical Terminology, Healthcare Compliance
Software: MS Suite, Epic Systems, 3M 360 encoder, 3M 360 Encompass system
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